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LDA - Louisiana Dental Association

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LADPAC CHIPPING IN FOR DENTISTRY<br />

7th Annual Golf Tournament<br />

Registration Form<br />

Friday, October 23, 2009<br />

Pelican Point Golf Club, Gonzales, La.<br />

ENTRY FEE: $150 (includes lunch & reception)<br />

AGENDA<br />

10:30 a.m. Registration & Lunch Begins (Mulligans Available for Purchase)<br />

11:30 a.m. Shotgun Start*<br />

Tournament ends 19th Hole Reception and Tournament Awards and Prizes<br />

* Full details will be mailed to all registered golfers.<br />

Thanks to our sponsors: Robert Ellis & Associates, 3M ESPE, The Olivier Group,<br />

Campus Federal Credit Union, and Roedel Parsons. (9/2/2009)<br />

Registration : Sign up individually or as a team. Individuals will be put together to form teams.<br />

Name _______________________________________________ Telephone Number ______________________________<br />

Address ____________________________________________________________________________________________<br />

E-mail ____________________________________ Fax _____________________________________________________<br />

Golf handicap ________________________________________<br />

If you have already arranged to play with another player or players, please provide their names (and golf handicaps). Also include any of the<br />

other players on your team or any other players you would like in your foursome:<br />

___________________________________________________________________________________________<br />

___________________________________________________________________________________________<br />

Number of players ($150 each) = $<br />

Pre-pay for mulligans (limit 2 = $10) = $<br />

*Add late fee of $20 per person after Oct. 19 = $<br />

Credit card convenience fee ($15) = $<br />

Total amount of fees due to the <strong>LDA</strong> = $<br />

Payment Information<br />

Check enclosed (check box) Payable to LADPAC<br />

Visa/MasterCard Expiration Date ___________________<br />

Card Number ___________________________________<br />

Three-Digit Code, Back of Card ____________________<br />

Signature ______________________________________<br />

Register online at www.ladental.org or<br />

send completed form to:<br />

LADPAC Golf Tournament<br />

P.O. Box 261173,<br />

Baton Rouge, LA 70826-1173<br />

Phone: (225) 926-1986 or 800-388-6642<br />

Fax: (225) 926-1886 or 800-343-3842<br />

info@ladental.org or www.ladental.org<br />

Beginning August 1, 2009, there will be a $15<br />

convenience fee for each credit card transaction.

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